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BACK PAIN - BHS Education Resou · PDF fileNonspecific back pain in detail ... cauda equina, conus medullaris. ... Compression syndromes Cord, cauda equina, conus medullaris

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Text of BACK PAIN - BHS Education Resou · PDF fileNonspecific back pain in detail ... cauda equina,...


    Thoracic & Lumbar Spine

  • Last updated Feb 20122

    Session Aims

    Define acute, subacute& chronic presentation Focus on assessment of common problem Learn risk assessment for serious causes Nonspecific back pain in detail Detail on not to miss diagnosis

  • Last updated Feb 20123


    Very common problem: second after URTI to primary health Commonest work-related disability

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    Acute = 12/52

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    VASCULAR AAA, Thoracic Aortic Dissection

    Infection Epidural abscess, osteomyelitis, discitis

    Osteoporotic crush # Malignancy Compression syndromes Cord, cauda equina, conus medullaris

  • Last updated Feb 20126


    Musculoskeletal m.spasm, ligament Disc - >90% L4-5/L5-S1 Osteoporotic crush # Malignancy

  • Last updated Feb 20127


    Osteomyelitis bacterial, TB Epidural abscess Discitis

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    Vascular dissection, leaking aneurysm, AMI Pancreatitis PE Renal PNR, colic (Non-organic)

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    General risk factors - HISTORY

    Pain >6/52 Age50 (tumour, infection) Minor trauma in elderly (crush #s) Fever, rigours Weight loss (tumour, infection) IVDU Immucompromise Nocturnal pain, pain at rest Incontinence Saddle anaesthesia Past Hx cancer

  • Last updated Feb 201210

    General risk factors - EXAM

    Fever, writhing in pain (infection) Anal sphincter laxity (compression) Perineal Sensory loss Major motor weakness (nerve root or cord

    compression) Positive SLR (disc herniation)

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    Aortic dissection, rupturing AAA, spinal epidural abscess and PE most commonly dont present in a classical way

    The best way to make these diagnoses is by specifically considering them and looking for risk factors

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    Vital signs are important! Examine the abdomen The back itself Neurological examination Straight leg raise Consider PR examination

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    Examination of the back For evidence of infection (skin etc.) Point tenderness for infection and fractures sens 86%, spec 60%

    Range of motion not helpful

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    Lower limb neuro exam


    L4 L5 S1







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    For L4 test anterior lower thigh

    L5 test lateral calf S1 posterior calf

    and lateral foot

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    Distribution of pain

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    Determining level of cord compression

    Establish a sensory level

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    Straight Leg Raise

    Lie pt. down, passive leg raise, knee extended

    Stop when patient says to, note where pain is Dorsiflex ankle at this point True positive is: Sciatic or radicular pain below knee Not back pain or buttock pain pain elicited before hamstrings move pelvis

    Specific not sensitive for disc prolapse

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    PR examination who gets one?

    Anyone with faecal retention, incontinence, saddle anaesthesia

    Consider in anyone with severe pain Any neurological defecit Looking for: Mass (prostate, rectal) and rule out abscess Rectal tone and saddle sensation (compression)

  • Last updated Feb 201220

    Nasty diagnoses reminder

    VASCULAR AAA, Thoracic Aortic Dissection

    Infection Epidural abscess, osteomyelitis, discitis

    Osteoporotic crush # Malignancy Compression syndromes Cord, cauda equina, conus medullaris

  • Last updated Feb 201221

    Thoracic Aortic Dissection

    Classic Hx: sudden onset, tearing chest pain, radiates

    interscapular less than 1/3

    Examination: HTN (1/3 normal BP), BP dif. Arms >20 (?25%, often in normal people) new diastolic murmur (sens. 28%)

    Most signs AFTER the catastrophe!

  • Last updated Feb 201222

    Ruptured AAA

    Classic triad: Abdo pain, low BP, pulsatile mass

  • Last updated Feb 201223

    Aortic catastrophe risk factors

    Usual vascular RFs: Male, old age, HTN, Smoking

    Aortic abnormalities: Connective tissue disease, chromosomal

    abnormalities, inflammatory aortic conditions, bicuspid aortic valve, aortic instrumentation

    PREGNANCY Illicit drug use esp. cocaine,


  • Last updated Feb 201224

    pitfall Aortic catastrophes (dissection and AAA) can

    present with neurological symptoms In 18-36% pt.s with dissection! Acute stroke Unilateral leg weakness (radicular artery)

    About 5% AAA rupture pt.s Haematoma around AAA pressure on femoral n. can cause weak hip and knee flexion

  • Last updated Feb 201225

    Aortic imaging guidelines AAA exclusion needs to done in any elderly patient

    with new onset severe back pain Ultrasound can be used to determine size of aorta

    (ED ultrasound widely used for this) Doesnt determine leak or rupture Normal size aorta wont do this

    Age greater than 55 and severe back pain? Use CT to diagnose renal colic or diverticulitis

  • Last updated Feb 201226


    classic triad: fever, back pain, neurological defecit

    occurs only 13% 75% afebrile, 2/3 normal initial neurological exam Risk factor Ax best chance ID before neuroprob

  • Last updated Feb 201227

    Epidural abscess risk factors

    Recent epidural/spinal anaesthetic** Generally related to immunocompromise Normal immune reaction leads to symptoms!

    Diabetes Alcoholism Chronic renal failure Steroid use HIV/AIDS IVDU

  • Last updated Feb 201228

    Staph most common isolated organism About 1/3 gram negative Requires prompt antibiotic treatment GN requires 3rd generation cephalosporin GP requires Blactamase stable penicillin

    and consider vancomycin if ?MRSA Needs urgent Confirmation of diagnosis MRI now surgical consultation: May do biopsy to isolate organism B4 ABs

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    Spinal metastases

    Risk factor is malignancy of any type Commonest are prostate, breast, lung Also MM, lymphoma, RCC, bowel

    Need to think about cord compression

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    Can present as back pain Should also do a risk factor assessment for

    thromboembolism This is a talk for another day!

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    INVESTIGATION - bloods

    Looking for infection FBE can be normal, but ESR always elevated, ?CRP too

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    IMAGING - Xray

    Very few indications according to some for Xrays to investigate non-traumatic back pain

    Possible indications: For suspected fracture, tumour, infection Cant be relied on to exclude: Sensitivity spine met.s only 60%, 17% cord

    compression Xray normal, 2/3 osteomyelitis normal first 7-10/7

    Oblique views are NOT necessary Extra radiation and insenstive

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    Sensitive for spinal metastases, fractures Can identify disc prolapse, but Inferior to MRI Doesnt show cord or spinal canal well

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    Only investigation able to exclude compression syndromes

    For suspected infection For soft tissue tissue tumours

  • Last updated Feb 201235

    Disc Prolapse most important issue is motor radiculopathy

    only 2-3% of acute lower back pain have this need prompt referral, urgent MRI & surgeon r/v

    within a week probably reasonable 95% are at L4/L5 or L5/S1

    Neurology at lower level eg. L4/L5 causes L5 lesion Acute surgical indications for motor symptoms Isolated sensory problems generally not a problem

  • Last updated Feb 201236


    Preferred terminology to sprain/strain, mechanical, lumbago (most people never get more specific diagnosis,

    no histopath strain) Usu. mild to moderate pain exacerbated by movement, relieved with rest often minor exertion, lifting, may not be any

    clear etiology

  • Last updated Feb 201237

    Management - EXPLANATION

    Explain reason for lack of imaging: Pathology not important

    Reason for not admission: normal activities better than exercise or bed rest

    What to do and not to do leg lifting not back in and out of bed not heat & massage for 24H

    Explanation re use of pain killers Likely time course and GP follow up

  • Last updated Feb 201238

    Mx - analgesia

    Paracetamol first line, regular NSAIDs not significantly better, more SEs Avoid ketorolac in: elderly, risk renal failure, peptic ulcer disease

    Opiates for: moderate to severe pain, short term, GP consultation

    muscle relaxants eg diazepam: controversial not better than NSAIDs, no added benefit

  • Last updated Feb 201239

    Opiates and permits It is a requirement of Department of Human Services, Health Insurance

    Commission, and Medical Practitioners Board of Victoria that any opiate prescription beyond short term requires permit with ONE medical practitioner.

    Illegal and unprofessional to prescribe purely to maintain dependence or avoid withdrawel. Unprofessional to label someone a drug addict and leave them in

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